Inspection on 11/07/07 for Frodsham Christian General Care Home

This inspection was carried out on 11th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Frodsham Christian General Care... 16/04/08

Frodsham Christian General Care... 27/09/06

Frodsham Christian General Care... 09/02/06

Frodsham Christian General Care... 03/08/05

Frodsham Christian General Care... 21/03/05

Frodsham Christian General Care... 27/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Frodsham Christian General Care Home Chapelfields The Main Street Frodsham Cheshire WA6 7BB Lead Inspector Joan Adam Unannounced Inspection 09:00 11th July 2007 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000018744.V332456.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000018744.V332456.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Frodsham Christian General Care Home Address Chapelfields The Main Street Frodsham Cheshire WA6 7BB 01928 734743 01928 734745 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Trinity Care Homes Limited vacancy Care Home 70 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (30), Old age, not falling within any other of places category (40), Terminally ill (3) DS0000018744.V332456.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 70 service users to include: * Up to 40 service users in the category of OP (old age not falling within any other category) * Up to 3 service users in the category of TI (terminally Ill) * Up to 30 service users in the category of DE(E) (dementia- over 65 years of age) * Up to 1 service users in the category of DE (dementia) 27th September 2006 Date of last inspection Brief Description of the Service: Frodsham Christian Care Home is a purpose built care home with separate units providing nursing care for 40 elderly frail people, and 30 people who have dementia. The home has two storeys and all bedrooms are single rooms with en suite facilities. There is a choice of lounges with a communal dining room on the ground floor of the unit for elderly people, and lounges and separate dining facilities on both floors of the dementia unit. In addition there are accessible ground floor gardens, and a large patio area, both of which are enclosed. The home is situated within a very short walk of the town centre. Public transport services, i.e. trains and buses are accessible close to the home. A planned programme of care is drawn up for each service user, which are reviewed monthly, or as required. Trained nursing staff are on duty twentyfour hours a day. The weekly fee payable at the home ranges from £390.35 to £678. The manager provided this information. DS0000018744.V332456.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit took place on 10th July 2007 and took seven hours. It was carried out by two inspectors of the Commission The visit was just one part of the inspection. The home was not informed of the date the visit was to take place, but a few weeks prior to the visit the manager was asked to complete a questionnaire to provide the inspector with some information about the service. The manager was also asked to distribute questionnaires to residents, relatives and health and social care professionals to help the inspector find out what they think of the home. One response was received from a GP who visits the home. This doctor commented that they were satisfied with the overall standard of care provided, and that staff demonstrate a clear understanding of peoples’ needs. Comments from residents such as “the home was always clean” “we could do with some decorating soon” “ the staff are really nice here” was made during the visit. During the visit the inspector spoke with the manager, staff and residents. The premises and various records held by the home were looked at. Two hours were spent observing the care being given to a small group of people. Feedback was given to the registered manager at the end of the inspection. What the service does well: Positive relationships were observed between residents and staff. Interactions were kindly and reassuring. Visitors to residents were made to feel welcome and are enabled to continue to share the caring role. Staff members are encouraged to undertake training to increase their skills and knowledge base, and to meet the changing needs of residents. Residents are offered choice in their daily lives and the standard of catering is good. Residents are treated as individuals and their privacy and dignity is respected DS0000018744.V332456.R01.S.doc Version 5.2 Page 6 Recruitment procedures, staff training and staff supervision ensure that residents are protected from harm. Residents’ financial interests are also safeguarded. The home is clean and comfortable with a warm and welcoming atmosphere. What has improved since the last inspection? What they could do better: Care planning information, security, fire safety training and notification of accidents could be improved for the benefit of residents. Complaints records need to be fully completed to ensure residents and relatives know their complaint has been fully investigated and action has been taken to resolve the complaint. Redecoration, improved lighting on the corridors and re-carpeting is necessary and would further improve the environment for residents and staff. Notifications must be sent to CSCI by the manager or person in charge to enable CSCI to record actions taken by the home in response to accidents or incidents occurring. The notice will then form part of the record of evidence for the care home. The registration details of the trained staff were not available at the home on the day of the site visit and following requests by the inspector this information has not been sent to CSCI. This information is needed to ensure trained staff registration with the Nursing and Midwifery Council are up to date. The electrical wiring in the home must be checked and an up to date certificate must be obtained to maintain the safety of the residents living at the home. DS0000018744.V332456.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000018744.V332456.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000018744.V332456.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents needs are not fully assessed prior to admission so that staff know if they can fully meet their care needs. EVIDENCE: The records of three people recently admitted to the home were examined. All contained a pre-admission assessment that had been carried out by a suitably qualified and experienced member of staff. On the EMI unit a newly admitted resident had a full assessment completed which contained information regarding care, social and mental health needs. DS0000018744.V332456.R01.S.doc Version 5.2 Page 10 On the frail elderly unit one of the assessments seen was for a person recently taking up accommodation at the home. At the time of assessment this person had a sacral pressure sore but this was not identified on the assessment documentation, nor had the body map been filled in. The assessment for skin integrity was blank. The need for a pressure relieving mattress was identified but not to what specification. The home does not provide intermediate care. DS0000018744.V332456.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were care plans for people living in the home but these did not always cover all of their care needs to make sure that all their needs were met appropriately. EVIDENCE: Care plans were in place at the home and two were looked at on the EMI unit. These contained adequate information to enable care staff to meet the needs of these residents. Risk assessments were in place for behavioural problems and staff were aware of what to do to de-escalate any challenging behaviour. Care plans were also in place on the frail elderly unit and two were looked at. One resident had a pressure sore on admission and was dehydrated. A moving and handling assessment was completed but an assessment regarding skin integrity had not. A nutritional assessment completed identified that she was at risk and a plan of care had been written for eating and drinking. However, there was no reference in the plan to the swallowing problems the resident suffers with or of the assistance required at meal times. A fluid balance chart DS0000018744.V332456.R01.S.doc Version 5.2 Page 12 had been commenced, but no reference was made as to the amount of fluid required over a 24 hour period. The resident has an indwelling catheter in place but no catheter care has been identified in the plan of care. There was no plan of care in place regarding the sacral pressure sore which they were admitted with and a spenco mattress on their bed was unsuitable to maintain skin integrity and prevent the sore from deteriorating. The daily notes which were written were informative. One resident had been weighed in February 07 and the weight was recorded as weighed 56.1 kg. In June 07 the weight recorded was 47.1 kg. This resident is reported to refuse most food offered and a record was seen of the family being aware of this. However, guidance as to how to encourage her to eat and drink could have been included in her care plans. A risk assessment regarding falls was in place, but this had not been dated or evaluated. A plan of care in place which was dated 05.02.07 stated that the resident had a pressure sore on their sacrum, however, no evaluation was recorded. When asked, the nurse said that she did not have a pressure sore, but a carer added that she had a red mark where she lay. A Spenco mattress was on the bed, however, given the weight loss of this person and her refusal to take a nourishing diet a higher specification of mattress is required. This issue of using the correct mattress was discussed with the manager at the home at the site visit. Records were seen of doctors and other healthcare professionals being involved in the care of people living at the home. One person was giving particular concern on the day of inspection. Their GP was contacted who visited and examined the person, following which a new course of treatment was prescribed for the person. A comment card was filled in by one of the GP’s that visit the home. This doctor commented that they were satisfied with the overall standard of care provided, and that staff demonstrate a clear understanding of peoples’ needs. Medication management was looked at on both units. On the EMI unit medications were managed well and storage arrangements were satisfactory. The home used a monitored dosage system. Medication Administration Record Sheets were completed appropriately. Controlled Drugs were checked and the balances were correct on both units in the home. A daily check is made by the nursing staff on a daily basis and a record is made. On the frail elderly unit there are two medicine refrigerators, one of which is sited on a shelf at the end of a downstairs corridor. Whilst this was locked it is not very secure, and there is room for this in the medicines storage room on the first floor where both trolleys are kept. It is recommended that this be moved to the medicines storage room and this was discussed with the manager. DS0000018744.V332456.R01.S.doc Version 5.2 Page 13 Eye drops were dated upon opening but a bottle of Calogen ( which has a shelf life) had not. Medication Administration Record Sheets were completed appropriately. Staff observed to be aware of the need to maintain the dignity and privacy of people when providing personal care for them. They were seen to be friendly and supportive when interacting with people. There is a desk and filing cabinet on the first floor of the elderly frail unit that staff use as a work station. The care records of one person were lying on the top of the desk along with the ‘turning’ and personal hygiene records of people. A book labelled as a shower/bath book was on the top of the filing cabinet that contained the dates of when people were bathed/showered. These records showed that there was a gap of nine days between showers/baths. Such records should not be on show, and the filing cabinet, which stored care records was not locked, which breaches the confidentiality of the residents living in the home. DS0000018744.V332456.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of daily living and activities available are flexible and varied to suit residents’ expectations, preferences and capacities. EVIDENCE: The home employs an activities co-ordinator and a programme of activities was displayed. One visitor spoken with said that social activities were well provided for. The activities organiser was holding a word quiz in the upstairs lounge on the frail elderly unit with a group of residents. Residents spoken with said that they enjoyed this. There is a quiet/prayer room for use by residents and relatives, and church services are held at the home on a regular basis. Visitors spoken with said that they are made to feel welcome when visiting and that they are kept informed. The home has an open visiting policy, and people can choose where they receive their visitors. DS0000018744.V332456.R01.S.doc Version 5.2 Page 15 There are two sittings at meal times on the frail elderly unit. The first sitting is for people who require assistance with eating their meal. Staff were observed to sit with people providing assistance in a calm and supportive manner giving encouragement when required. One visitor spoken with said that they thought this was a good idea, and that people had their meals in a more relaxed environment. People spoken with were complimentary about the food provided. Choice is available for the main courses, and a dessert is provided at the lunch and tea time meals. During lunch on the dementia unit the inspector spent time observing the interaction between staff and residents in the dining room. Staff were found to be patient and took the time to ask residents what they wanted rather than deciding for them. Residents were supported to feed themselves but when staff felt assistance was required, such as residents stopping feeding themselves, this interaction was done sensitively. DS0000018744.V332456.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints received by the home are not accurately recorded therefore residents and their relatives are unclear as to whether any action has been taken to resolve the complaint. EVIDENCE: The complaints procedure is displayed and residents said they would know how to complain. The complaints procedure is also contained within the Service User Guide (information leaflet) so that residents are aware of their rights. The home’s complaints log was inspected. The pre-inspection questionnaire received from the acting manager of the home identified that there have been five complaints received within the past twelve months. However, it was not possible to track these as the information in the ‘log’ was not present. On 25th May 2007 a letter of complaint was received at the home and an acknowledgement letter regarding this was sent to the complainant on the 30th May . There was no further information regarding this complaint i.e. no investigation record, nor an outcome The log showed that a complaint was received on 2 May 2007. There were no details regarding this apart from a record being made that it had been received. DS0000018744.V332456.R01.S.doc Version 5.2 Page 17 The log showed that in March 2007 a complaint was outstanding from February 2007. The February 2007 log also showed that there was an outstanding complaint from January 2007. It was not possible to tell if this was one or three different complaints for the three months. An entry in the log stated that a ‘letter sent in response to family’ but no further details were recorded. None of the complaints was satisfactorily recorded or provided adequate details of investigation. Frodsham CNH has a policy for the protection of vulnerable adults and staff receive training in this area. Staff spoken to were aware of the actions to take in the case of suspected abuse. The home has had POVA issues since the last inspection and these have been dealt with appropriately. DS0000018744.V332456.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some areas of the home need to be improved to ensure that residents live in a comfortable environment. The home was clean and fresh. EVIDENCE: The home employs a maintenance person for the day to day repair and redecoration of the home. The home is in general looking “tired” and shabby and is in need of some refurbishment. Lighting in the home needs to be improved especially in the corridors. DS0000018744.V332456.R01.S.doc Version 5.2 Page 19 The manager said that a budgetary allowance has been identified for the replacement of some carpets, furniture and light fittings around the home but she was unaware of where or when these would be replaced. This had been discussed at the last inspection in September 2006 however a date for work to commence has not been given. Upstairs on the dementia unit there was a radiator coming loose from the wall which could trap residents’ fingers. This was reported to the manager who said she would deal with this immediately. In the main bathroom the flooring was becoming unstuck where it meets the wall. In the shower room there was no mirror in place and a large patch of unpainted wall where one had previously been. Shelving had also been removed and the wall was unpainted and marked where the shelf had been. The staff spoken with said that this had been like this for some time and as the shower room is used on a daily basis the decoration should be improved. On the main corridor on this unit a small store cupboard was in place. This had been built in pine type wood but it was not easy to keep clean and the doors did not close properly. All of the bedrooms at the home are supplied with the ensuite facilities of a toilet and wash hand basin. Additional toilets are sited within close proximity to the bedrooms and day areas. Baths that are adapted for use with people unable to get into and out of a bath unaided are on all of the units, and walk in showers are provided for use with people who prefer a shower to a bath. A number of bedrooms were visited at this inspection. These were seen to be comfortably furnished and well personalised by people occupying them or by members of their family. All areas of the home were visited and found to be clean, tidy and free from unpleasant smells. One visitor was complimentary about the standard of laundry service provided. DS0000018744.V332456.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and skill mix are sufficient to meet the needs of the residents, Residents are protected by the home’s recruitment practices and staff training. EVIDENCE: There were adequate numbers of staff on duty to meet the needs of the residents living at the home. There is ongoing training in place at the home for staff. A training matrix was seen. Training provided included pressure area care, moving and handling, fire awareness, first aid and dementia care. A training programme is in place to enable staff to achieve NVQ level two in care. The home has seventy three per cent of care staff who have completed the course. Good policies and procedures are in place for the recruitment of staff. Four staff files were seen and each contained evidence of an interview, two references and the necessary CRB checks having been obtained before the staff member commenced duties. Evidence was seen to show that all staff working in the home have had a Criminal Records Bureau check completed. DS0000018744.V332456.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some areas of recording need to be improved to ensure that the residents’ safety is maintained. EVIDENCE: The home manager has been in her present post for nine months, prior to which she was the registered manager of another care home. She said that she was waiting for a Criminal Records Bureau form to complete and when received she would make application to the Commission to become the registered manager of Frodsham CNH. DS0000018744.V332456.R01.S.doc Version 5.2 Page 22 Staff spoken with said that they found the manager supportive and willing to listen. The interactions observed between the manager and staff were open and friendly. The systems for the recording of any monies or valuables held were good. Records were seen of a representative of the company carrying out monthly unannounced inspections at the home when they spoke with people living at the home, the staff, toured the premises, and inspected the care and home’s records. Accidents are audited on a monthly basis that show the total number of accidents each month, the type of accident sustained and the times of these. It was suggested to the manager that the location of accidents be looked at to ascertain whether there were any particular areas in the home where accidents were prevalent. Records of complaints made to the home need to be logged and action taken recorded so that residents and relatives are confident that they are taken seriously. The pre inspection questionnaire completed by the manager stated that there had been twenty nine deaths at the home in the last year, however, CSCI have only been notified of eight of these deaths. Regulation 37 notices need to be sent to CSCI, the notice will then form part of the record of evidence for the care home. Records were seen of staff and relatives meetings being held, and of a residents’ meeting in April 07. Information regarding the registration numbers of trained nurses working at the home had not been given to CSCI on the pre-inspection questionnaire. The manager was unable to give this information to the inspector at the time of the site visit and was asked to send the information to CSCI office. A telephone call was made to the manager some days after the inspection however this information has not been received. It is the employers responsibility to confirm a registered nurse’s qualifications with The Nursing and Midwifery Council prior to employment and to ensure that the nurses registration with the Nursing and Midwifery Council are up to date. The pre inspection questionnaire provided information to confirm that equipment and installations at the home are serviced on a regular basis. However, the home has not had an electrical wiring safety report completed since 2001. The manager informed CSCI that work would commence On 30th July 2007. A copy of the certificate should be forwarded to CSCI. DS0000018744.V332456.R01.S.doc Version 5.2 Page 23 The home employs a handyman who attends to maintenance issues such as checking fire equipment, water temperatures and other health and safety matters, providing some areas in the home to be safe. DS0000018744.V332456.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 DS0000018744.V332456.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO DS0000018744.V332456.R01.S.doc Version 5.2 Page 26 STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 (2) (b) Requirement The registered person must ensure that all residents needs are fully assessed before they are admitted to the home so that they know their needs can be met. The registered person must ensure that there is an up to date written plan of care of each resident, to enable their changing needs can be met. Where a person living in the home has been assessed at high risk of developing pressure sores or has developed pressure sores, an appropriate mattress must be provided to ensure that the risk of developing pressure sores is reduced and that the most appropriate nursing care is given. The registered person must ensure that a record of all complaints made by residents or representatives or relatives of residents is kept along with details of the action taken by the registered person in respect of any such complaint. The registered person must ensure that a programme of replacement furniture and redecoration be put in to place with a timescale of starting and DS0000018744.V332456.R01.S.doc Timescale for action 04/08/07 2 OP7 17 (1)(a) 04/08/07 3 OP7 12 (b) 04/08/07 4 OP16 17(2) Schedule 4. 11 04/08/07 5 OP19 23(20 (d) 28/09/07 Version 5.2 Page 27 6 OP31 8 completion. The registered person must ensure that the manager in post has made an application to be registered with CSCI. 12/09/07 7 OP38 37(1)(2) 8 OP38 13 (4) (a) 9 OP38 19(5) (b) CSCI must be notified of any 04/08/07 incidents that could compromise the health and safety of the people in the home and of any allegation of misconduct of a person working in the home. These incidents must be reported as soon as possible after the event and appropriate action take. The registered person must 04/08/07 ensure that the electrical wiring of the home is checked to ensure the safety of residents and staff and an up to date certificate received. A copy of the certificate must be sent to CSCI. The PIN numbers of all nursing 04/08/07 staff must be checked, to ensure that trained staff have an up to date registration with the Nursing and Midwifery Council, and a copy of the information sent to CSCI. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000018744.V332456.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000018744.V332456.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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